The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 1

Scientific Articles | January 01, 2007

Internal Oblique Radiographs for Diagnosis of Nondisplaced or Minimally Displaced Lateral Condylar Fractures of the Humerus in Children

Kwang Soon Song, MD¹; Chul Hyung Kang, MD¹; Byung Woo Min, MD¹; Ki Chul Bae, MD¹; Chul Hyun Cho, MD¹

¹ Department of Orthopedic Surgery, School of Medicine, Keimyung University, 194 Dong san dong, Daegu, South Korea. E-mail address for K.S. Song: skspos@dsmc.or.kr

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Disclosure: The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopedic Surgery, Keimyung University, Daegu, South Korea

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J Bone Joint Surg Am, 2007 Jan 01;89(1):58-63. doi: 10.2106/JBJS.E.01387

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Abstract

Background: Several radiographic criteria based on only standard anteroposterior and lateral radiographs have been suggested for predicting the stability of lateral condylar fractures of the humerus in children. Despite adherence to these guidelines, further displacement often occurs after the initial diagnosis and stability assessment. The purpose of this study was to define the usefulness of an internal oblique radiograph in the assessment of these fractures.

Methods: We prospectively studied fifty-four lateral humeral condylar fractures in fifty-four children seen between March 2002 and December 2004 to determine the efficacy of internal oblique radiographs in gauging the amount of displacement and the fracture pattern. Plain anteroposterior, lateral, internal oblique, and external oblique radiographs were initially made for all fifty-four patients, and three-dimensional computed tomography scans were performed for seven patients.

Results: A large percentage (70%) of the fractures were seen to have different amounts of displacement on the anteroposterior and internal oblique radiographs, and a large percentage (75%) were seen to have different fracture patterns, according to the criteria suggested by Finnbogason et al., on the two views. The internal oblique radiograph was more accurate for demonstrating the fracture gap (thirty cases were seen to have more displacement on that view) and for demonstrating the fracture pattern (twenty cases were seen to have more instability on the internal oblique view). We also confirmed the direction of the fracture line and the location of the fragment more accurately with three-dimensional computed tomography.

Conclusions: It is not optimal to evaluate the amount of displacement and the stability of a lateral condylar fracture of the humerus in children on the basis of just anteroposterior and lateral elbow radiographs. Classifications should be based on the greatest displacement seen on at least three radiographic views, especially the internal oblique view.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Lateral condylar fracture of the humerus is the second most common fracture of the elbow in children. Open reduction and internal fixation of displaced unstable fractures usually produces good results, as does closed treatment with a posterior plaster splint or a long arm cast for nondisplaced and minimally displaced fractures^1-6. However, despite adherence to published guidelines^5-10, displacement may occur while the arm is immobilized in a plaster cast. Several criteria based on standard anteroposterior and lateral radiographs have been suggested to predict the stability of these fractures^5,7,11. We believe that there can be a large difference between anteroposterior and internal oblique radiographs with respect to the degree of displacement that is seen and the fracture pattern that is appreciated. We conducted a prospective study to define the usefulness of the internal oblique radiograph for determining the amount of displacement and the pattern of fractures of the lateral condyle of the humerus in children.

Materials and Methods

Materials and Methods | Results | Discussion | References

We prospectively studied fifty-four lateral condylar fractures of the humerus in fifty-four children seen between March 2002 and December 2004. We had excluded from the study six fractures that were classified as stage-3 displaced and rotated according to the system of Jakob et al.⁵, as such fractures have a clear diagnosis and a well-established need for surgical treatment. Plain anteroposterior, lateral, internal oblique, and external oblique radiographs were initially made for all fifty-four patients, and three-dimensional computed tomography was performed for seven. Three of us (K.S.S., C.H.K., and B.W.M.), who are experienced orthopaedic surgeons, measured the degrees of displacement and classified the fracture patterns with use of a PACS (Picture Archiving and Communication System) network (Marosis, DICOM version 3.0; INFINITT, Seoul, South Korea).

Displacement was measured from the lateral metaphyseal cortex of the distal part of the humerus to the lateral cortex of the fracture fragment on the anteroposterior, internal oblique, and external oblique radiographs. The posterior cortex was used to measure the distance on the lateral radiograph. The measurement revealing the most displacement was recorded as the amount of displacement of the fragment. We classified all fifty-four fractures according to the amount of displacement and we classified twenty-eight fractures according to the fracture type, defined by the criteria suggested by Finnbogason et al.⁷, as seen on the anteroposterior and internal oblique radiographs (Tables I and II). We did not include the findings on the external oblique or lateral radiographs as these views provided no more information than did the anteroposterior and internal oblique radiographs alone.

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TABLE I Amount of Displacement of the Fifty-four Fractures as Seen on the Two Radiographic Views^*

	Internal Oblique Radiograph
Anteroposterior Radiograph	No Fracture Line	<1 mm	1-1.9 mm	2-2.9 mm	3-3.9 mm	4-4.9 mm	5-5.9 mm	6-6.9 mm	7-7.9 mm	8-8.9 mm	9-9.9 mm	10-10.9 mm
No fracture line	1	1	7	0	1	0	0	0	0	0	0	0
<1 mm	1	2	1	3	1	0	1	1	0	0	0	0
1-1.9 mm	0	0	2	3	1	0	1	0	0	0	0	0
2-2.9 mm	0	0	0	4	1	1	0	0	0	1	0	0
3-3.9 mm	0	0	0	1	1	0	1	0	0	0	0	0
4-4.9 mm	0	0	0	0	1	2	1	0	0	0	0	0
5-5.9 mm	0	0	0	0	0	0	0	0	0	0	0	0
6-6.9 mm	0	0	0	0	0	2	0	0	1	0	0	0
7-7.9 mm	0	0	0	0	0	0	0	1	1	1	0	0
8-8.9 mm	0	0	0	0	0	0	1	0	1	1	1	0
9-9.9 mm	0	0	0	0	0	0	0	0	0	0	1	1
10-10.9 mm	0	0	0	0	0	0	0	0	0	0	0	1

The values are given as the number of fractures

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TABLE I Amount of Displacement of the Fifty-four Fractures as Seen on the Two Radiographic Views^*

	Internal Oblique Radiograph
Anteroposterior Radiograph	No Fracture Line	<1 mm	1-1.9 mm	2-2.9 mm	3-3.9 mm	4-4.9 mm	5-5.9 mm	6-6.9 mm	7-7.9 mm	8-8.9 mm	9-9.9 mm	10-10.9 mm
No fracture line	1	1	7	0	1	0	0	0	0	0	0	0
<1 mm	1	2	1	3	1	0	1	1	0	0	0	0
1-1.9 mm	0	0	2	3	1	0	1	0	0	0	0	0
2-2.9 mm	0	0	0	4	1	1	0	0	0	1	0	0
3-3.9 mm	0	0	0	1	1	0	1	0	0	0	0	0
4-4.9 mm	0	0	0	0	1	2	1	0	0	0	0	0
5-5.9 mm	0	0	0	0	0	0	0	0	0	0	0	0
6-6.9 mm	0	0	0	0	0	2	0	0	1	0	0	0
7-7.9 mm	0	0	0	0	0	0	0	1	1	1	0	0
8-8.9 mm	0	0	0	0	0	0	1	0	1	1	1	0
9-9.9 mm	0	0	0	0	0	0	0	0	0	0	1	1
10-10.9 mm	0	0	0	0	0	0	0	0	0	0	0	1

The values are given as the number of fractures

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TABLE II Classifications, According to the Finnbogason Type, of the Twenty-eight Fractures as Seen on the Two Radiographic Views^*

	Internal Oblique Radiograph
Anteroposterior Radiograph	No Fracture Line	Type A	Type B	Type C
No fracture line	1	6	0	2
Type A	1	2	3	7
Type B	0	0	2	2
Type C	0	0	0	2

The values are given as the number of fractures

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TABLE II Classifications, According to the Finnbogason Type, of the Twenty-eight Fractures as Seen on the Two Radiographic Views^*

	Internal Oblique Radiograph
Anteroposterior Radiograph	No Fracture Line	Type A	Type B	Type C
No fracture line	1	6	0	2
Type A	1	2	3	7
Type B	0	0	2	2
Type C	0	0	0	2

The values are given as the number of fractures

The fractures were classified into five groups according to the difference in the degree of displacement shown on the anteroposterior radiograph compared with that seen on the internal oblique radiograph. Fractures were considered to be in group A when the same fracture gap was seen on both the anteroposterior and the internal oblique radiograph, in group B when a larger gap was seen on the anteroposterior radiograph, in group C when a larger gap was seen on the internal oblique radiograph (Figs. 1-A and 1-B), in group D when the fracture was seen to be unstable (displacement of >2 mm) on the anteroposterior radiograph and stable (displacement of <2 mm) on the internal oblique radiograph, and in group E when the fracture was seen to be unstable on the internal oblique radiograph and stable on the anteroposterior radiograph (Figs. 2-A and 2-B).

We also divided the fractures into five groups according to the classification system of Finnbogason et al.⁷, who used radiographic criteria to determine fracture stability. With this system, type A indicates a fracture through the lateral humeral condyle with a minimal lateral gap (a stable fracture); type B, a fracture through the lateral humeral condyle to the epiphyseal articular cartilage with a lateral gap (a fracture for which the risk of further displacement is undefinable); and type C, a fracture through the lateral humeral condyle into the joint with the fracture gap as wide laterally as medially (a fracture with a high risk of further displacement). Classification with the Finn-bogason system was appropriate for twenty-eight undisplaced or minimally displaced fractures, and these injuries were assigned to one of five groups. They were considered to be in group 1 if the same fracture type was seen on both the antero-posterior and the internal oblique radiograph, group 2 if a more unstable fracture type was seen on the anteroposterior radiograph than on the internal oblique radiograph, group 3 if a more unstable fracture type was seen on the internal oblique radiograph than on the anteroposterior radiograph, group 4 if an unstable fracture type (C) was seen on the anteroposterior radiograph and a stable or undefinable type (no fracture line, type A, or type B) was seen on the internal oblique radiograph, and group 5 if an unstable fracture type (C) was seen on the internal oblique radiograph and a stable or undefinable fracture type was seen on the anteroposterior radiograph.

We used the two-proportion population test to establish the significance of the differences between groups.

We performed three-dimensional computed tomography for seven fractures to verify the posterolateral location of the fracture fragment and the direction of the fracture line, but three-dimensional computed tomography was not used routinely to evaluate these fractures.

We obtained permission from the parents or guardians of each of these patients to conduct the study and to expose the patients to the risks of additional radiation. We also received approval from our institutional review board.

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Figs. 1-A and 1-B: Anteroposterior radiograph of the elbow, showing a Finnbogason type-B fracture (undefinable) in a six-year-old boy. Internal oblique radiograph of the same patient, showing a Finnbogason type-C fracture (unstable). The fracture gap was as wide or almost as wide medially as it was laterally, and there was 5 mm of displacement.

Results

Materials and Methods | Results | Discussion | References

We evaluated a total of fifty-four fractures (Table I) in thirty-six boys and eighteen girls whose ages ranged from twenty-two months to eleven years and six months (average, five years and eight months). Thirty-one fractures involved the left elbow, and twenty-three involved the right elbow.

Thirty-eight (70%) of the fifty-four fractures were considered to be in group B or C (different amounts of displacement seen on the anteroposterior and internal oblique radiographs), and sixteen were in group A (the same degree of displacement seen on both views). Thus, 2.4 times more patients were in group B or C than in group A, which was a significant difference (p < 0.001). There were thirty fractures (56%) in group C (more displacement seen on the internal oblique radiograph), a number that was 3.8 times higher than the number of fractures (eight) in group B (more displacement seen on the anteroposterior radiograph). This difference was also significant (p < 0.001). Finally, there were thirteen patients (24%) in group E (the fracture appearing to be unstable on the internal oblique radiograph and stable on the anteroposterior radiograph), whereas there were no patients in group D (the fracture appearing to be unstable on the anteroposterior radiograph and stable on the internal oblique radiograph). Again this difference was significant (p < 0.001).

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Figs. 2-A and 2-B: Anteroposterior radiograph of the elbow, showing a Finnbogason type-A fracture (stable) in a ten-year-old boy. Internal oblique radiograph of the same patient showing a Finn-bogason type-C fracture (unstable) traversing the capitellum.

On the basis of the classification according to the Finn-bogason type (Table II), twenty-one (75%) of the twenty-eight patients were in group 2 or 3 (different fracture types seen on the anteroposterior and internal oblique radiographs), a number that was three times greater than the number of patients (seven) in group 1 (the same type of fracture seen on both views) (p < 0.001). There were twenty patients in group 3 (a more unstable fracture seen on the internal oblique radiograph), a number that was significantly higher (p < 0.001) than the number (one) in group 2 (a more unstable fracture seen on the anteroposterior radiograph). There were eleven patients in group 5 (an unstable fracture seen on the internal oblique radiograph and a stable or undefinable fracture seen on the anteroposterior radiograph), whereas there were none in group 4 (an unstable fracture seen on the anteroposterior radiograph and a stable or undefinable fracture seen on the internal oblique radiograph) (p < 0.001).

In this series, the percentages of lateral condylar fractures in which the degree of displacement (70% of the cases) and the fracture type (75% of the cases) differed between the anteroposterior and internal oblique radiographs were high. The internal oblique radiograph demonstrated the degree of displacement, used to assess fracture stability, more accurately than did the anteroposterior radiograph.

Discussion

Materials and Methods | Results | Discussion | References

The anatomic cause of nonunion of fractures of the lateral condyle of the humerus in children is instability of the distal fragment, but the most common cause is inadequate treatment of a fresh fracture^12-17. The primary care physician, and sometimes the orthopaedist, may not diagnose the fracture accurately because some fractures are not fully appreciated on only one radiographic view¹². The optimal treatment of minimally displaced and nondisplaced lateral condylar fractures in children is a matter of debate. The difficulty in treating these injuries arises mainly from the difficulty in determining whether the distal fracture fragment is prone to further displacement. Several reports have suggested that the integrity of the articular cartilage hinge at the distal humeral epiphysis determines the stability of these fractures. If the cartilage of this hinge is disrupted, the fracture is complete, and such an injury should be considered unstable and predisposed to further displacement^5-9. Many other imaging studies, such as magnetic resonance imaging, arthrography, stress tests, and ultrasonography, have been suggested as additional methods for the evaluation of fracture stability^8-11,18. However, routine use of these modalities may not be warranted as a result of their high cost and the need for sedation.

In general, radiographic criteria have been widely used to evaluate lateral condylar fractures^13,19. The criterion for instability has ranged from 2 to 4 mm of displacement^{8,10,14-16,20}. The Finnbogason type-C fracture has been considered unstable because it is a complete fracture with a high risk of subsequent displacement. Despite adherence to these guidelines, many have reported an increase in fracture displacement after immobilization, in a long arm cast, of a lateral condylar fracture that was initially thought to be stable and nondisplaced or minimally displaced. Radiographic studies of displacement and stability of lateral condylar fractures have demonstrated variable results, and most authors have assessed the fractures on the basis of only anteroposterior and lateral radiographs^{7,8,10,15,21,22} or by comparing the radiographs with drawings and reproductions of anteroposterior and lateral radiographs found in textbooks^{5,12,14,17,23,24}. Only a few reports have focused on the oblique radiographic view^25,26. Bast et al. evaluated fracture displacement on anteroposterior, lateral, and internal oblique radiographs and reported that, on reevaluation of two failures of closed reduction, both patients were seen to have had an initial displacement of 2 mm on the internal oblique radiograph and that the initial treatment should have been open reduction and internal fixation¹⁶. However, we found no previous prospective study on the contribution of internal oblique radiographs to the accuracy of the initial diagnosis of lateral condylar fractures of the humerus in children^27,28.

Marzo et al. stressed that the amount of displacement seen may differ with varying degrees of obliquity of the radiograph beam¹⁰. We found that the external oblique and lateral radiographs provided no more information than did the anteroposterior and internal oblique radiographs alone. Our prospective study showed high percentages of patients with differences in the amount of displacement (70% of the cases) and the fracture pattern (75% of the cases) shown on the anteroposterior radiograph compared with the internal oblique radiograph. Rang et al. reported that internal oblique radiographs show the fracture gap and pattern more accurately and precisely because the fragment is located posterolaterally in many cases²⁸. We also found that, in many of our patients, the fracture fragment was located posterolaterally, not purely laterally, and we confirmed the direction of the fracture line and the location of the fragment more accurately with use of three-dimensional computed tomography in seven patients. We recommend that an internal oblique radiograph be made if a lateral condylar fracture is suspected in a child. This study demonstrated that it is not optimal to evaluate the amount of displacement and stability of the fracture on the basis of only anteroposterior and lateral radiographs. The internal oblique radiograph should be used routinely to evaluate the amount of fracture displacement and to assess stability when the initial treatment of these fractures is being planned. ?

References

Materials and Methods | Results | Discussion | References

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Crabbe WA. The treatment of fracture-separation of the capitular epiphysis. J Bone Joint Surg Br. 1963;45: 722-6.45722 1963

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Finnbogason T, Karlsson G, Lindberg L, Mortensson W. Nondisplaced and minimally displaced fractures of the lateral humeral condyle in children: a prospective radiographic investigation of fracture stability. J Pediatr Orthop. 1995;15: 422-5.15422 1995 [PubMed][CrossRef]

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Marzo JM, d'Amato C, Strong M, Gillespie R. Usefulness and accuracy of arthrography in management of lateral humeral condyle fractures in children. J Pediatr Orthop. 1990;10: 317-21.10317 1990 [PubMed][CrossRef]

Milch H. Fractures and fracture dislocations of humeral condyles. J Trauma. 1964;4: 592-607.4592 1964 [PubMed][CrossRef]

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Flynn JC, Richards JF Jr, Saltzman RI. Prevention and treatment of non-union of slightly displaced fractures of the lateral humeral condyle in children. An end-result study. J Bone Joint Surg Am. 1975;57: 1087-92.571087 1975

Badelon O, Bensahel H, Mazda K, Vie P. Lateral humeral condylar fractures in children: a report of 47 cases. J Pediatr Orthop. 1988;8: 31-4.831 1988 [CrossRef]

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Topics

fracture ; humerus ; humeral fractures, lateral condylar ; internal oblique

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Kwang Soon Song, Chul Hyung Kang, Byung Woo Min, Ki Chul Bae, Chul Hyun Cho; Internal Oblique Radiographs for Diagnosis of Nondisplaced or Minimally Displaced Lateral Condylar Fractures of the Humerus in Children. The Journal of Bone & Joint Surgery. 2007 Jan;89(1):58-63.

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